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Best Practices for Sustained Community Engagement Learned from the STRETCH 2.0 Midpoint Best Practices for Sustained Community Engagement from STRETCH Jessica Fepelstein The brief reflects on critical takeaways and key insights from a community health and health equity program. Creating systemic change within state public health agencies while simultaneously curating authentic, sustainable relationships with community partners can be challenging. Whether it’s issues with sustainable funding, conflicting priorities, or the toll of undertaking transformative work, making progress in these areas are often slow-moving. To assist state agencies with this work, the Strategies to Repair Equity and Transform Community Health (STRETCH) Initiative was born. Funded by the Robert Wood Johnson Foundation, STRETCH is a co-creation between ASTHO, the CDC Foundation, and the Michigan Public Health Institute focused on building lasting, systemic change to advance equity in all sectors of public health. The first iteration of STRETCH was from October 2021 through May 2023, with STRETCH 2.0 launching in January 2024 and going through May 2025. During STRETCH 1.0, its creators learned that community partners not only needed to be more involved in assisting state public health agencies in setting their equity priorities, but also needed to be leading this work in step with agency staff and leadership at the onset of decision-making conversations. Therefore, in STRETCH 2.0, community-based organizations became the project's primary applicants and fiduciary recipients, creating a state collaborative with public health agency staff. Collaboratives from seven states comprise the STRETCH 2.0 cohort, who receive technical assistance and support via personalized core response teams and engage in peer-to-peer learning through monthly practical application workshops. Creating this level of learning and sharing among states was another key lesson learned by the STRETCH partners; those working in health equity and systems change are hungry for connection with their peers. These connections not only allow staff to share best practices and common pain points, but also allow them to lean on each other emotionally and create a space of psychological safety in this sometimes-taxing work. This lesson has been operationalized with the creation of the STRETCH Network of Health Equity Practitioners virtual community. This community is open to anyone in the health equity and/or systems change public health ecosystem who would like to connect with fellow practitioners, participate in monthly “Speak and Share” discussions, and receive additional materials and best practices from across the country. Also open to the public are the STRETCH 2.0 national convenings, quarterly virtual events aimed to disseminate STRETCH lessons and create a connected network of systems change practitioners. These national touchpoints aim to expand the reach of the STRETCH initiative beyond the cohort and allow all state public health agencies to better operationalize health equity and move towards lasting, systemic change. Midway through the second iteration of STRETCH, there are already key themes and critical takeaways the partners have observed while working with the cohort of state collaboratives. Among them is ensuring community voice is always front and center in all state public health initiatives, even internal operations. Secondly, valuing the lived experiences of community members and their organizations—particularly with financial incentives—is a critical component in ensuring capacity for this valuable work. Finally, while having a plan is beneficial, the ability to be flexible and meet the needs of the collaboratives as they shift is a critical aspect of success when working on multi-sector initiatives. Key Takeaways: Lessons Learned Midway through the STRETCH 2.0 Cohort With Us, Not for Us Centering community voice is not a novel concept in community engagement and health equity efforts. One of the best practices the STRETCH initiative has found in centering community voice is allowing each state collaborative to set the purpose and agenda for their core response team’s site visit. One participant from South Carolina expressed that this model of having “on the ground” partners in charge of planning the visit was a key success of the experience and recommended continuing the use of this model moving forward. On a micro-level, this is an example of the importance of centering the community’s voice and allowing those with lived experience to lead the work. Along with systemic change, this focus on community leading the work is a central tenant of the STRETCH Initiative. Time is Money Another common theme in health equity work is the lack of sustainable funding to achieve systemic change, specifically when working directly with community partners and nonprofit organizations. To reduce the financial burden of participating in STRETCH, the second iteration of the project offered funding directly to the applying community-based organization to assist in strengthening the organization’s capacity to fully engage with this work right at the beginning. Providing a financial investment for the project not only allowed organizations to dedicate time, staff, and resources to the work of STRETCH, but it also “walked the walk” in terms of valuing community members' lived experience and expertise. While strengthening community compensation guidelines and initiatives is not novel to the STRETCH project, it is a key component of the success of the second iteration. Flexibility is Critical While the STRETCH partners did plenty of planning when developing the program’s activities, a critical theme of the initiative has been learning to meet each state collaborative’s unique and ever-changing needs throughout their participation. Whether it was leadership changes, hurricane responses, or shifts in staffing capacity, each state was faced with its own unique needs and challenges over the first half of STRETCH 2.0. A key lesson learned from the project is understanding how to alter plans and meet the states where they are with what they need, rather than focus on creating a uniform experience. In practice, this has taken shape by turning check-in meetings into working sessions, providing virtual and in-person options for relationship-building activities, and staggering site visits throughout the project year based on the priorities of each state. By remaining flexible and working in step with state collaboratives to best meet their needs, the STRETCH project has continued to be valuable to all cohort members. Want to learn more about the STRETCH project and other work of ASTHO’s Programmatic Health Initiatives and Strategies team? Check out the STRETCH framework microlearning course, our website, or email the team. article yes

Evidence-Based Approaches to Promoting Health Equity in Retail Food Safety ASTHO, Association of State and Territorial Health Officials, health equity, food safety, health in all policies, foodborne illness, public health, food code, food service employees, food safety resources, safety standards, barriers to food safety, retail food safety, communication barriers, diversity of language, understand and implement, educational resources, culturally respectful, food science, impacted populations, equitable enforcement, best practices, food safety training, community health, conduct inspections, control measures, jurisdiction demographics Heather Tomlinson ASTHO | Public health agencies can incorporate health equity into their food safety work by tailoring their messages and strategies to their communities. Foodborne illness is costly, preventable, and all too common. Public health agencies are responsible for food safety and reducing foodborne illness by educating and inspecting retail food establishments. Several studies have found that independent ethnic restaurants—those that serve food originating from a culture or heritage of certain ethnic groups—had more violations and, as a result, were inspected more frequently than the average. Some of these violations may be related to a misunderstanding of the food code and/or language barriers. Currently, more than one in four food service employees speaks a language other than English at home and 22% of employees have less than a high school diploma. It is crucial that food safety resources and messaging provided by public health agencies be made available to reflect varying languages and literacy proficiencies to ensure accessibility and comprehensibility for all. Achieving health equity, in which everyone has a fair and just opportunity to attain their highest level of health, requires health agencies to evaluate their approaches to food safety so all food establishments can meet retail food safety standards. Addressing Communication Barriers Health agencies should be familiar with the diversity of languages and cultures in their jurisdiction so materials can be tailored to each community’s differing needs. Providing food safety training courses, regulations, and other materials in languages spoken by local restaurant staff can reduce barriers so restaurant operators and workers who don’t speak or read English fluently have access. Having interpreters or multilingual inspectors can drastically improve communication between inspectors and restaurant staff. For health agencies without these resources, inspectors can utilize photos or translation services, such as Google Translate or language lines, to communicate effectively with restaurant operators. Demonstrating proper practices in person or through videos can also help communicate through observation. With more than half of U.S. adults aged 16 to 74 years old reading below the equivalent of a sixth-grade level, food safety educational resources should be developed so that all populations have access to documents written at educational levels tailored for their community. Educational materials should meet plain language accessibility requirements, including limited text in the appropriate language and simple cultural appropriate imagery. Food safety inspectors can carry materials in multiple languages or have online resources they can share with the retail food facility, such as Washington’s Food Worker Manual or FDA’s Educational Posters that provide flyers on common food safety topics. Finally, newly developed resources should include the target audience in development and pilot testing to ensure they are achieving the desired impact. Designing Materials to Support Your Audience Being familiar with cultural norms and communicating in a culturally sensitive way can enhance the delivery of food safety messaging. One study found that produce safety education materials developed for produce growers in the U.S. Virgin Islands were not seen as culturally appropriate. After redesigning the materials based on community feedback, the managers saw improvements in food safety knowledge and hygiene practices among produce growers. These results and similar studies suggest that educators should partner with impacted populations to evaluate the utility of potential interventions before implementation and ensure they are interpreted as intended. In addition to culturally appropriate food safety education materials, agencies can ensure that they meet the practical needs of the retail environment. For example, materials targeted for mobile facilities (i.e., food trucks) may need to be durable and waterproof to withstand operation and transportation. Ensuring Equitable Enforcement at Your Health Agency Health agencies can incorporate concepts such as equitable enforcement and health equity into their staff’s annual training curriculum. Equitable enforcement promotes compliance with law and policy that considers and minimizes harm to people affected by health inequities. ChangeLab Solutions’ guide on Equitable Enforcement to Achieve Health Equity educates policymakers, advocates, and enforcement officials on best practices in the design and development of enforcement provisions to avoid inequitable impacts and promote community health. A study from Michigan State University found that food safety professionals throughout the United States, especially at the local level, encountered a variety of ethnic food establishments and ethnic foods for which they lacked relevant food safety training. The smartphone application, Cultural Food Safety App, offers searchable information on food safety issues and control measures associated with specific culturally based foods. This app can help regulators better understand cultural foods and their production to ensure foods are being safely prepared and be more familiar with what to look for when conducting inspections. Lastly, health agencies can incorporate a Health in All Policies framework into their food safety practices through ASTHO’s Food Safety Guides. ASTHO strongly supports health agencies in promoting a diverse and culturally competent food safety workforce. By assessing jurisdiction demographics, addressing communication barriers, tailoring resources to fit the audience, and building a culturally competent workforce, health agencies can improve equity in their jurisdiction’s food safety programs. 5U18FD007739-02 website yes

Fairfax County Health Department Modernizes Infrastructure to Optimize Public Health Data Sharing Susan Fluerant, Reema Mistry, Christina Severin Learn how the Fairfax County Health Department in Virginia is working to modernize its data infrastructure & optimize public health data sharing. Using lessons learned from the COVID-19 pandemic, the Fairfax County Health Department (FCHD) is coordinating with county agencies, the Virginia Department of Health (VDH), and nonprofit public health organizations to modernize its data infrastructure and optimize public health data sharing functions. FCHD’s Informatics and IT team engaged in a strategic process to develop a multiyear IT roadmap, which outlines solutions and systems required to support this modernization, including clinical services, communicable disease surveillance, laboratory information systems, communication systems, and solutions for community engagement and administrative needs. As a result, FCHD is well-positioned to leverage its robust IT and data infrastructure to align with VDH for better data sharing. Advancing IT and Informatics Infrastructure Challenges associated with manual data-sharing processes (e.g., the use of CSV files to ingest data and produce analyses) during the COVID-19 pandemic prompted FCHD to reassess its informatics capacity. It conducted department-wide needs assessments and identified the need for improved technology, increased workforce capacity, and better data governance policies. It then ascertained IT functions that could be outsourced (e.g., cloud-hosted solutions and managed services for FHIR HL7 implementation) versus core public health functions (e.g., manipulating and managing data for epidemiologic use) that needed to remain internal, allowing FCHD to preserve internal staff capacity for key public health activities. Public health staff found working with CSV files to be inefficient for large or frequently updated datasets. To address this challenge, FCHD worked closely with VDH and the Fairfax County Informatics and IT team to adopt automated processes and develop a data warehouse solution—allowing FCHD to manage and transform data from multiple sources as well as control the frequency and timing of data retrieval, enhancing their ability to respond promptly to public health needs while keeping data secure on cloud-host servers. VDH hosted an API for FCHD to retrieve death data, significantly increasing flexibility and reducing the need for manual intervention. As FCHD increases the use of new data sources and technology, it continues to develop data governance policies, roles/responsibilities for data users, and data safeguarding guidance. Noel Clarin - Brief - Fairfax VA DMI to Optimize Public Health Data Sharing Engaging State and Local Partners FCHD recognizes that data sharing agreements are vital to support data exchange and, until recently, relied on informal data sharing agreements among other jurisdictions in Virginia. It partnered with attorneys at the state and local levels to work toward a universal data sharing agreement, which can expedite the data sharing process when public health programs have new use cases for local data. As a result, FCHD executed a Memorandum of Understanding with VDH in less than six months—a notable improvement from past data sharing agreements, which historically could take over a year to execute. They worked collaboratively through complex technical and bureaucratic challenges, highlighting the iterative nature of establishing effective data sharing protocols. FCHD also supported relationship-building between programs and divisions within the Fairfax County government, allowing for greater strategic alignment around emerging technologies. Interdepartmental relationship-building between public health program staff and the Fairfax County IT team has been equally important to foster effective collaboration and identify data modernization champions within FCHD. Alida Laney - Brief - Fairfax VA DMI to Optimize Public Health Data Sharing Planning for Sustainable and Diverse Funding Sources FCHD received an initial grant from the Public Health FHIR Implementation Collaborative through NACCHO, which helped launch the IT infrastructure improvement work; however, one-time funding is not a long-term solution. Now, FCHD is developing a long-term funding strategy to support the costs of IT systems licensing, operations and maintenance, and research and development. FCHD recognizes as public health changes, so must the technology that supports it, and modernization will require sustainable funding from government, associations, and other sources. Centering Health Equity in Informatics Solutions FCHD is developing processes to collect and standardize data disaggregated by sexual orientation and gender identity, race and ethnicity, language, and the social determinants of health to better identify and address health disparities. By incorporating additional data into its systems, program staff can now make informed decisions to strengthen health literacy by disseminating information in preferred languages and easy-to-read formats, and ensuring materials are accessible to persons with colorblindness. Ben Klekamp - Brief - Fairfax VA DMI to Optimize Public Health Data Sharing(2) Implementation Considerations Foster relationships within and across local and state government to get buy-in for the modernization of public health informatics infrastructure and the improvement of data-sharing practices. Define clear goals for implementing new technology, and build a strategy for infrastructure improvement, partner engagement, and long-term sustainability that’s grounded in a shared understanding of the goals. Align workforce responsibilities, process improvement efforts, and technological advancements. Develop universal data sharing agreement templates between state and local health departments to expedite future data-sharing efforts. OT18-1802 website yes

Wisconsin is leaning into teamwork to address homelessness and safe housing in the state.

Communicating About Disease Forecasting Effectively Communicating About Disease Forecasting Clearly communicating about disease forecasting helps policymakers, the media, and the public make informed decisions in public health emergencies. Communicating effectively about disease forecasting data is essential for the public to understand the associated risks, implications, and recommended actions. It’s also critical for policymakers who can use the data to determine effective, equitable strategies for outbreak response. In turn, the public can make informed decisions to keep safe. Each audience, including the media, will likely need tailored messages about the indications and limitations of a given forecast. Approaches for communicating about disease forecasts/models with policymakers and the public align with many of the key tenets of public health communications more broadly. Public health practitioners should consider integrating Crisis and Emergency Risk Communication (CERC) principles, which suggest that communications be first, right, credible, empathetic, actionable, and respectful to help the public make informed decisions during challenging circumstances. Communicating with Policymakers Policymakers—public health or elected—have important decision-making and rule-making authority; additional considerations may be needed when communicating with them about disease forecasting. Interactions frequently occur through staffers, who may have limited knowledge and/or time. In addition to CERC principles, communications should also be: Relevant. Tailor communications to policymakers’ priorities to emphasize potential impacts on resource allocation, public health outcomes, local or regional policies, and public sentiment. Collaborative. Foster relationships with policymakers and offer subject matter expertise on forecasting to inform policy decisions. Timely. Provide frequent updates, allowing for proactive collaboration, decision-making, and communication with the public. Concise. Develop briefs that summarize forecasts and their implications for constituents. Consistent. Build trust with policymakers and their staff between emergencies to highlight disease forecasting as a useful tool whose methodologies, data sources, and limitations are clear. Communicating with the Public In addition to CERC principles and in collaboration with media partners, communication about disease forecasts/models with the public should be: Accessible. Provide easily accessed information about methodology, data sources, and limitations in the forecasts. Clear. Use jargon-free, non-technical language to convey critical messages. Contextualized. Frame forecasts within the broader public health context, emphasizing how individual and community actions can mitigate risk, and reinforce the effects of collective actions as part of an outbreak response. Empowering. Give the public reasonable, actionable steps to protect themselves and their communities. Local. Use social media, news releases, listening sessions, and other relevant means to reach as broad an audience as possible. Collaborate with community leaders and health care providers to amplify messaging and reduce misinformation. Frequent. Keep the public informed with regular updates on forecast products including changes in local risk levels, new trends, guidance, and recommendations. Utah’s Best Practices for Communicating Forecasts During the COVID-19 response, the Utah Department of Health and Human Services (DHHS) modeled potential disease transmission and shared how to effectively communicate with the media and public. DO Create diverse forecasting and communications teams that include public health, universities, and ‘bonus’ team members (e.g., political representatives, laboratories, and health economists). Clarify the purpose for which a given model was developed. Discuss the limitations of the disease model. Communicate about future outcomes (i.e., what would happen without further intervention). Provide language on how to alter the current path (e.g., ‘With this intervention, we could potentially avoid…’) Remind audiences that models can affect the future, not only predict it. Share information and data that are digestible for the public. DON’T Sound definitive when outcomes aren’t clear or make predictions using absolute terms. Omit a variety of scenarios or tools when presenting a forecast. Disregard inherent uncertainties in forecasts. Show models with conflicting results. Utah DHHS also recognized that members of the media are key partners in communicating public health messages; closely coordinating and contextualizing forecasts helps communicate accurate conclusions and/or recommendations. Communicators and staff should be prepared and have information ready to share for more complex questions as needed. Storytelling with forecasts and models helps the reader internalize them and make informed decisions. CDC-RFA-OT18-1802 2018-2024 article yes

Enhancing Consumer Awareness Improves Access to Risk-Appropriate Care Lexa Giragosian Enhancing consumer awareness can improve health outcomes for pregnant and birthing populations. Risk-appropriate care (RAC) is a strategy to ensure that pregnant women and infants with high risk of complications receive care at facilities with personnel and services that can provide the required level of specialized care. States can utilize the process of perinatal regionalization to create coordinated care systems based on levels of maternal care (LoMC) to support RAC access. Implementing and strengthening maternal RAC systems as well as enhancing consumer awareness can improve health outcomes for pregnant and birthing populations and reduce the incidence of severe maternal morbidity and mortality. Maternal Mortality in the United States The U.S. maternal mortality rate nearly doubled between 2018 and 2021, with the starkest increases occurring among American Indian/Alaska Native and Black populations. Among other high-income nations, the United States has one of the highest maternal mortality rates and is continually increasing. According to the Maternal Mortality Review Committee's most recent data, over 80% of pregnancy-related deaths are preventable, and barriers such as low consumer awareness can inhibit the prevention of pregnancy-related deaths. The Importance of Consumer Awareness Consumer awareness refers to patient’s knowledge, attitudes, and awareness about their health. There is a gap in understanding among pregnant and non-pregnant women of the major health risks associated with pregnancy or what can pose a risk during pregnancy. There are also challenges surrounding consumer awareness of what levels of maternal care are, and which level is right for everyone. More specifically, there is a common misconception that higher levels are always the safest level to receive care. A lack of consumer awareness is associated with poor health outcomes and can create gaps in access to RAC. Providers have an important role in improving consumer awareness by educating their patients about their pregnancy risk factors and levels of maternal care, while also having adequate awareness about levels of maternal care themselves. Provider awareness about levels of maternal care can promote RAC accessibility since providers are often the main point of contact for pregnant women and are responsible for ensuring the patient receives care at the appropriate level. State Success Strategies Support and work with communities to build capacity for addressing consumer awareness. Promote community organizations’ ability to improve pregnant women’s understanding and usage of health information (literacy, language instruction, social support, etc.) to enhance consumer awareness and corresponding health outcomes. Specifically, supporting women of color-led community organizations will foster equitable consumer awareness. Implement and support policies that make doulas and community health workers more accessible within communities. Develop and disburse public health campaigns about maternal health. Utilize effective health communication techniques rooted in health equity. CDC’s Hear Her Campaign is an effective public health campaign that increases awareness of pregnancy complications and warning signs, empowers pregnant people to raise their concerns to their provider, encourages support systems to listen to pregnant people’s concerns, and provides the tools needed to foster communication between providers and patients. Ensure that health education materials are accessible and consider the social factors affecting the priority population. Inclusive and preferred language in educational materials should be applied and understandable, actionable, and culturally sensitive. Form partnerships with providers, hospitals, foundations, and professional associations to take a collaborative approach toward improving consumer awareness. Create resources with these relevant partners to inform patients about how to choose a provider and a hospital based on the level of care their pregnancy risks indicate. The National Accreta Foundation has a myriad of resources to help patients navigate the care process and ensure their access to RAC. Utilize partnerships with key stakeholders to disseminate materials in prenatal care settings such as provider offices or hospitals that outline RAC and the care coordination system in place at that location. Ensure that transferred/referred patients are receiving materials about the reason for their transfer/referral and about the new level of care they are entering. website yes

Infographic depicting findings on a survey around opioid use among pregnant people.

U.S. Virgin Island’s Federal Grant Planning and Set Up Process Improvement ASTHO, Association of State and Territorial Health Officials, u.s. virgin islands, grant management, federal grant planning, grant planning, workflow visibility, cross agency leadership, federal grant management, community of practice, cross agency, oversight responsibilities, standard process, facilitate workflow, community of practice cop Kristin Sullivan, Colton Anderson ASTHO | Recommendations to improve speed and quality of the U.S. Virgin Island’s Federal Grant Management processes. This infographic details strategies for improving the speed and quality of the U.S. Virgin Islands’s Federal Grant Management “Plan and Set Up” process. Get the Infographic (PDF) website yes

Strengthening Grant Management Functions in Puerto Rico ASTHO | Toolkit helps to optimize grant activities and funds in Puerto Rico The Grants Management Office Structure Optimization Toolkit helps to assess a health department's federal grant workload, staffing requirements in its grant management office, and potential to optimize grant management activities. The Puerto Rico Department of Health (PRDOH) is using it as a guide for improving internal grants management capacity and oversight to maximize federal funding outcomes. PRDOH anticipates increased information flow, a more inclusive culture, and additional benefits. Get the Infographic in English (PDF) Obtén la infografía en español (PDF) website yes

Federal lawmakers have a long list of public health priorities to address before the current fiscal year ends on September 30, 2023, including must-pass annual appropriations, reauthorizing the Pandemic and All-Hazards Preparedness Act, and taking on emerging challenges such as the opioid epidemic and drug shortages.

Effective Public Health Approaches to Reducing Congenital Syphilis astho, association of state and territorial health officials, provider bias, syphilis screening requirements, medicaid family planning programs, medicaid eligibility, congenital syphilis, musculoskeletal defects, pregnant people, public health, trans men, medicaid family planning, gender identity, early congenital syphilis, tested for syphilis, neutral terms, blood test, musculoskeletal system, inclusive language, reproductive health, medicaid coverage, transgender and nonbinary people, medicaid programs, family planning benefits, birth control, carpal tunnel syndrome, musculoskeletal disorders, treponema pallidum, gender neutral language, health care Julia Greenspan, Alex Kearly, Rachel Scheckman, JoAnne McClure, Sanaa Akbarali Effective Public Health Approaches to Reducing Congenital Syphilis Rates of congenital syphilis (CS)—when an infant contracts the disease during pregnancy or birth—are continuing to climb at an alarming rate in the United States. Although preventable, rates more than tripled between 2017 and 2021, with more than 2,800 cases reported in 2021 alone. CS can cause stillbirth, infant death, or other serious and permanent complications including musculoskeletal defects (e.g., impairments in the muscles, bones, and joints leading to temporary or lifelong limitations in functioning), vision and hearing problems, and developmental delays. An ASTHO technical package is a summary of a select group of related interventions that, taken together, help achieve and sustain improvements related to risk factors or health outcomes. ASTHO technical packages are based on programmatic subject matter experts' assessment of evidence-based interventions, expert recommendations, overviews of current activities, and a review of CDC and other federal funding guidance. They are not intended to be comprehensive and can be iterative. ASTHO’s Congenital Syphilis Technical Package focuses on policy-level interventions that states and territories can pursue starting in pregnancy. ASTHO acknowledges other evidence-based or promising policy interventions that broadly address sexually transmitted disease (STI) prevention that are not reflected in this technical package. Further, this technical package will be updated when updates to CDCs guidance on recommended syphilis screening for pregnant persons are available. A summary of ASTHO’s Congenital Syphilis Technical Package is outlined in the this table. Increase Universal Screenings for Pregnant Persons Testing pregnant people for syphilis at three points of pregnancy—first and third trimesters and at delivery—is an evidence-based approach to reduce CS. The American College of Obstetricians and Gynecologists and CDC currently recommend universal first trimester screening and additional screening for those who are at risk or live in areas of high rates of syphilis. However, these screening recommendations rely on providers’ knowledge of the epidemiology in their area and to take patient histories to accurately judge risk. Additionally, jurisdictions may have other laws or recommendations that reflect variability in testing requirements. Jurisdictions can increase syphilis screening of pregnant people by modifying their laws to require screening at three points during pregnancy. They can do so through direct authority of state health officials, Medicaid, state medical licensing boards, and other enforcement mechanisms. How Public Health can Leverage Medicaid to Reduce CS Rates Medicaid provides coverage for low-income adults nationwide and covers more than 40% of all births. Syphilis rates are nearly six times higher among women insured through Medicaid compared to women insured through commercial insurance. Optimize Medicaid Eligibility, Services, and Providers for At-Risk Pregnant People and their Partners States can expand eligibility for Medicaid Family Planning Programs, which provide family planning benefits and STI services to people who would not otherwise qualify. In most states, services are available for individuals up to 200% Federal Poverty Level (FPL). Some states (e.g., Iowa) are expanding eligibility beyond that threshold. Additionally, implementing State Plan Amendments (SPA) to expand Medicaid postpartum coverage can allow coverage of postpartum treatment for syphilis. States can work with Medicaid agency partners to ensure Medicaid services comprehensively cover STI testing, treatment, and counseling with minimal cost-sharing. States can also submit 1115 waivers to cover unmet health-related social needs, or HRSN services (e.g., housing, nutrition, transportation), that exacerbate poor health outcomes and should be addressed in tandem with medical treatment. Further, states can weigh in on Medicaid managed care organizations (MCO) contract requirements to ensure coverage of HRSN services. States can leverage alternative provider types, such as community health workers (CHWs), doulas, and perinatal case managers to facilitate access to services, encourage first and third trimester STI screenings, and provide support services. Currently, nine states and Washington D.C. reimburse doula services under Medicaid. CHWs are already providing services for people living with HIV and can perform a variety of roles, improving access to care for people with syphilis. They can help with care coordination, coaching, providing social support and health education. S/THAs can work with their Medicaid agency partners to submit an SPA or 1115 waiver to cover CHWs, doulas or perinatal case managers, or create managed care requirements to require use of these provider types. Incentivize Providers to Comply with Universal Syphilis Screening Requirements S/THAs can work with Medicaid agency partners to adopt and incentivize the Prenatal and Postpartum Care CMS Core Measure (National Committee for Quality Assurance Measure #1517) as part of the state’s quality strategy. Incentivizing the quality measure encourages providers to meet performance metrics through a financial incentive. Further, states can update practice guidelines to encourage providers to conduct universal STI screenings during prenatal care visits, including syphilis testing in the first and third trimester. S/THAs can work with their Medicaid agency partners and MCOs to develop additional provider incentives. For example, AmeriHealth Caritas—a Louisiana-based MCO—offers provider incentives for third trimester syphilis testing. The performance is measured based on the percent of live deliveries that had at least one test for syphilis. Practices that score above the 55th percentile for third trimester screenings are eligible for bonus payments. States can also partner with their Medicaid agency partners and incentivize consumers through MCOs. Several states offer incentive programs for pregnant persons who attend one or all prenatal appointments. For example, Kentucky offers gift cards and South Carolina offers items such as strollers or car seats. Establish an Implementation Plan for the Quality Strategy S/THAs can work with their Medicaid agency partners to develop consumer education materials, including information on how to enroll in Medicaid, covered services, provider availability, and how to reduce the risk of CS. Targeted enrollment outreach to pregnant persons in their first trimester is critical for early testing and treatment since being screened for syphilis is more likely if a person is enrolled in Medicaid earlier. S/THAs can also work with their Medicaid agency partners and MCOs to ensure Medicaid providers are aware of quality measure changes and how to leverage incentive payments by including information through communication materials including Medicaid provider bulletins and state quality strategies.   Establish Cross-Agency Collaboration and Governance Structures A critical step in ensuring implementation of payment incentives and legislation is creating mechanisms for S/THAs and their state Medicaid agencies to better coordinate services and polices directed toward low-income individuals at risk for CS and other syndemic conditions. Strategies for cross-agency collaboration and governance could include: Establishing a joint Medicaid/public health quality committee related to syndemics (e.g., CS and/or HIV). Creating a standing policy body that has a designated position for OB/GYN physician leaders to advise and engage in practice change. Building relationships and engaging with Medicaid quality committees to highlight public health data, policy, best practice, and support available to respond to the rise in cases. Remove Barriers to Care by Addressing Stigma and Provider Bias Removing barriers to screening and treatment and addressing stigma and implicit bias are critical to reducing CS rates. Structural racism and prejudice contribute to and reinforce disparities in maternal and neonatal morbidity and mortality, including rates of CS. To address stigma, policymakers must implement strategies that address systematic prejudice and discrimination including developing systems that have several points of entry for care, provide culturally competent training for the providers and perinatal workforce, and fostering multi-sector referral relationships. Additionally, leveraging the perinatal workforce, including doulas, can support pregnant and postpartum people in seeking and remaining in prenatal and postnatal care. Doulas act as advocates and educators for pregnant people and using them improves maternal and neonatal outcomes. To increase access to doulas, states should consider expanding doula coverage under Medicaid. Medicaid reimbursement of doula services—which are typically covered out-of-pocket—helps make their services available to low-income and underserved populations. Blog - ASTHO's Congenital Syphilis Technical Package Conclusion States and territories can address the rise in CS infections by focusing on

Community members and policymakers that want to prevent suicides, overdoses, and adverse childhood experiences can choose to intervene at different levels.

As new diseases or emergencies arise, working alongside trusted committees can help health officials quickly respond and prevent undue burden on at-risk groups such as people with disabilities, pregnant people, and children.

This post examines the youth mental health and loneliness crises and shares guidance for how public health agencies can work alongside schools to address these crises through social connection.

Jonathan Mermin of CDC discusses how using a syndemic approach could help health departments to address rising STI rates more effectively

Late on June 26, 2023, five cases of locally acquired (i.e., non-travel related), mosquito-transmitted malaria were reported in Florida and Texas. To prepare for the future, health officials should consider critical infrastructure needs for vector surveillance and control.

Six DELPH scholars share personal reflections about LGBTQ+ identity, representation at work, and how allyship within public health leadership is critical when responding to a crisis.

Interest is using psilocybins to treat some disorders has reemerged. Some states are taking steps to put that interest into practice.

ASTHO asked six DELPH scholars to reflect on their DiSC assessment results and how they use the findings to tap into their leadership influence and impact.

Rural hospital closures exacerbate poor socioeconomic conditions, job loss, cost of health services, transportation times and barriers, and inequitable access to quality care, all of which contribute to unfavorable maternal and infant health outcomes.